The LDL cholesterol bands
| LDL-C, mg/dL (mmol/L) | Band | Where the line comes from |
|---|---|---|
| Under 70 (under 1.8) | Optimal | Guideline line, applied by Phoenix to every carrier. The 2026 ACC/AHA goal for adults at high risk. Carriers are not a guideline risk group, so using it for all carriers is a Phoenix choice. |
| 70 to under 100 (1.8 to under 2.6) | Monitor | Phoenix band. Worth working on. |
| 100 or higher (2.6 or higher) | Talk to your doctor | Guideline line. The 2026 ACC/AHA goal at borderline or intermediate risk. Bring it to your next appointment. It is not an emergency. |
The line rule. "Under 70" excludes 70, and "100 or higher" includes 100. So 70 is Monitor and 100 is Talk to your doctor.
Confidence in the optimal line: moderate. It is a real guideline goal, written for high-risk adults rather than carriers.
Why does LDL cholesterol matter more for a carrier?
Because APOE4 raises it, and because LDL does its damage over years.
APOE4 pushes LDL-C up one copy at a time. Across 82 studies of 86,067 healthy people, LDL-C climbed in a straight line across the APOE genotypes, and ε4/ε4 ran about 44 mg/dL higher than ε2/ε2 (Bennet, 2007).
LDL causes heart disease, and the harm adds up. A European Atherosclerosis Society consensus pooled more than 200 studies covering over 2 million people and found heart risk rose steadily with LDL-C, and rose further with every year of exposure (Ference, 2017). The 2026 ACC/AHA guideline puts the same idea at its centre: cumulative lifetime exposure.
The brain data point the same way. In 1.8 million people, higher LDL-C went with more dementia, and the link was strongest when LDL-C was measured before age 65 (relative risk 1.17 per 39 mg/dL for dementia diagnosed more than 10 years later) (Iwagami, 2021). The 2024 Lancet Commission lists high LDL cholesterol in midlife as one of 14 modifiable risk factors for dementia (Livingston, 2024). And in a 20-year Chicago cohort, higher total cholesterol sped up cognitive decline only in ε4 carriers (Ng, 2025).
So a carrier who lowers LDL-C early protects the heart for certain and the brain possibly. That is why Phoenix sets the line at 70, not 100.
What do the guidelines say?
- ACC/AHA (2026): LDL-C goal under 100 mg/dL at borderline or intermediate risk, under 70 at high risk, and under 55 for people at very high risk who already have heart disease.
- ACC/AHA (2018): an LDL-C of 190 mg/dL or higher is severe primary hypercholesterolemia, and the guideline starts a high-intensity statin without calculating 10-year risk (Grundy, 2018).
These goals were written for heart risk groups. APOE4 is not one of them.
Why did Phoenix choose under 70?
I chose under 70 because it is the guideline goal for high-risk adults, and a carrier who wants to protect both heart and brain belongs in that conversation.
The trials back a low line. Each 39 mg/dL (1 mmol/L) of LDL-C lowering cut major heart and stroke events by 22% and deaths from any cause by 10%, with no threshold below which the benefit stopped (CTT Collaboration, 2010).
I did not choose under 55, because the guideline writes that goal for people who have already had heart disease. And Phoenix's ApoB line, under 60, is already the stricter of the two: if your ApoB is under 60, your LDL-C is usually well under 70 too.
I carry APOE4/4 and I am working toward the same line (my numbers are below). I added ezetimibe 10 mg in spring 2025 and still take it.
How do you get LDL-C tested?
LDL-C comes on every standard lipid panel. Most labs calculate it from total cholesterol, HDL and triglycerides rather than measure it, and the old formula (Friedewald) undercounts at low levels. In 1.35 million US lipid profiles, when the Friedewald formula said LDL-C was under 70, the measured value was really under 70 only 61% of the time if triglycerides were 150 to 199 mg/dL, and only 40% of the time if they were 200 to 399 (Martin, 2013).
Two habits fix that. Ask your lab how LDL-C was calculated, and test ApoB alongside it.
You do not need to fast for LDL-C. After normal meals, LDL-C changed by at most 0.2 mmol/L (about 8 mg/dL) in 33,391 people (Langsted, 2008), and the 2018 guideline allows fasting or non-fasting screening (Grundy, 2018).
Units: divide mg/dL by 38.67 to get mmol/L. 70 mg/dL is 1.8 mmol/L and 100 mg/dL is 2.6 mmol/L.
What moves LDL-C?
Medicines move LDL-C by 20 to 60%. Food, fiber and weight move it by a few points each, and they add up. Ranked by size of effect:
| Lever | Typical LDL-C change | Source |
|---|---|---|
| PCSK9 inhibitor (evolocumab), on top of a statin | 59% lower, from 92 to 30 mg/dL | Sabatine, 2017 |
| Inclisiran (two injections a year after two starting doses) | About 50% lower | Ray, 2020 |
| High-intensity statin | 50% or more lower | Grundy, 2018 |
| Moderate-intensity statin | 30 to 49% lower | Grundy, 2018 |
| Ezetimibe added to a statin | About 23% lower (54 against 70 mg/dL) | Cannon, 2015 |
| Bempedoic acid (people who cannot take statins) | 21 percentage points lower than placebo | Nissen, 2023 |
| Plant sterols or stanols, up to about 3 g a day | 6 to 12% lower | Ras, 2014 |
| Psyllium fiber, about 10 g a day | About 13 mg/dL lower | Jovanovski, 2018 |
| Less added sugar | Higher sugar intake raised LDL-C by about 5 mg/dL | Te Morenga, 2014 |
| Weight loss through diet and exercise | About 1.3 mg/dL lower per kg lost | Hasan, 2020 |
| Less saturated fat | Small LDL-C drop; 21% fewer cardiovascular events in trials of 2 years or more | Hooper, 2020 |
| Aerobic exercise alone | No LDL-C change in trials (triglycerides fell) | Kelley, 2012 |
| Low-carbohydrate diet, against low-fat | About 6 mg/dL higher on average | Mansoor, 2016 |
Statins work just as well in carriers. In a meta-analysis by APOE genotype, the LDL-C response did not differ between ε4 carriers and ε3/ε3 (Zintzaras, 2009).
Phoenix members see the same gap between medicines and everything else. Among Phoenix members who uploaded two or more LDL-C results (as of 2 October 2026), those who have logged a lipid drug (ezetimibe, a statin, a PCSK9 inhibitor or bempedoic acid) lowered their LDL-C by a median 24% (21 mg/dL) between their first and latest test, and more than half of them (31 of 53) fell by 10% or more. Those who logged none lowered it by a median 3.3% (4 mg/dL), and 18 of 65 (28%) fell by 10% or more. That comparison counts anyone who ever logged a drug, without checking that it started between the two tests.
How often should you retest?
Retest LDL-C 4 to 12 weeks after starting or changing a medicine or a lifestyle change, then every 3 to 12 months. That is the 2018 ACC/AHA schedule, and the guideline judges the response by the percentage drop from your starting value (Grundy, 2018). So write down your baseline: a high-intensity statin should take it down by half or more.
What Phoenix members actually do: for LDL-C, the median span between a member's first and latest test is 298 days, about ten months, and 31% of repeat testers moved to a better band in that time.
My numbers
I carry APOE4/4. Here is my LDL-C before and after my changes:
| Date | LDL-C | Band |
|---|---|---|
| 13 December 2024 | 139 mg/dL (3.6 mmol/L), flagged high by the lab | Talk to your doctor |
| 7 August 2025 | 93 mg/dL, measured directly | Monitor |
That is 33% lower, from the talk band into Monitor. I made three changes close together: I moved to a Mediterranean-leaning diet, took about 10 g of psyllium before meals, and added ezetimibe 10 mg, my single best lever. I added ezetimibe in spring 2025 and still take it. My August result was measured directly, so the calculation problem above does not apply to it.
I am not under 70 yet. This is one carrier's result, not a promise of yours.
What Phoenix members' results show
Half of Phoenix members who uploaded an LDL-C result are at the talk line. Of 203 members (as of 2 October 2026), 35 (17%) have a latest value under 70, 65 (32%) sit between 70 and under 100, and 103 (51%) are at 100 or higher. The median is 100 mg/dL. Members with two copies of APOE4 look the same (120 members, 51% at 100 or higher).
The movement is real. Of 118 members who tested LDL-C more than once, the median result fell from 112.6 to 99 mg/dL over a median of 298 days, and 36 (31%) moved to a better band. In the 476-member Phoenix Research Release 001, 57 of 100 repeat testers lowered their LDL-C.
Two members from Release 001:
- Ezetimibe plus psyllium. An APOE4/4 woman in her 50s went from 263 to 78 mg/dL (70% lower) in 70 days, the largest lipid change in the report. She also used an estradiol patch and Lysoveta in the same window, and the report credits the size to the whole stack.
- A statin with probiotics. An APOE3/4 woman in her 40s went from 98 to 66 mg/dL (33% lower) in 59 days, into the optimal band.
Even the clearest drug needs numbers to prove itself. In Release 001, five members who started a statin lowered LDL-C by 38.6 mg/dL on average, against 10.3 for 56 members on no lipid drug. Telling a difference that size apart from noise takes about 23 members per group. More members testing is what turns signals like these into answers.
When should you talk to your doctor?
Talk to your doctor if your LDL-C is 100 mg/dL (2.6 mmol/L) or higher. That is the ACC/AHA goal at borderline or intermediate risk. Bring the result, your ApoB if you have it, and your family history to your next appointment.
At 190 mg/dL (4.9 mmol/L) or higher, do not wait for a routine visit. The 2018 guideline calls that severe primary hypercholesterolemia and treats it without first calculating risk (Grundy, 2018). Ask whether an inherited cause is possible, because it would matter for your relatives too.
Between 70 and under 100, the result is worth working on. If you already take a lipid-lowering medicine, keep it exactly as prescribed and bring any change to your doctor.